Provider Demographics
NPI:1336963016
Name:MACK, SEAN (LMBT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:MACK
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S RIDGEWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BLACK MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:28711-3511
Mailing Address - Country:US
Mailing Address - Phone:828-674-6188
Mailing Address - Fax:
Practice Address - Street 1:106 S RIDGEWAY AVE
Practice Address - Street 2:
Practice Address - City:BLACK MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28711-3511
Practice Address - Country:US
Practice Address - Phone:828-674-6188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22176225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist